EP237 - LIFT Procedure for Low Rectovaginal Fistula, A Viable Surgical Option?

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Purpose/Background: Benign rectovaginal fistulas (RVF) can be difficult to manage. The management approach is based on size, location, underlying cause and the type of fistula. RVF can arise from various etiologies, including obstetric trauma, pelvic surgery, pelvic irradiation, inflammatory bowel disease, neoplastic processes, and cryptoglandular disease. Low RVF originate distal from the anal sphincter complex and typically tracts to the posterior fourchette.

Current ASCRS guidelines for RVF management include placement of a draining seton for relief of acute inflammation/infection followed by definitive repair with endorectal advancement flap (success 41-78%), episioproctotomy (success 78%-100%), or tissue interposition flap (success 50-92%). These procedures can result in complications such as mucosal ectropion and fecal incontinence. The “Ligation of Intersphincteric Fistula Tract” or LIFT procedure is a well-established technique for treatment of fistula-in-ano with clinical success rates between 70-92%. It has not yet been described for the treatment of simple, low rectovaginal fistulas. Here, we report 3 patients who underwent LIFT procedure for treatment of low rectovaginal fistulas.

Methods/Interventions: Three patients with simple low rectovaginal fistulas were identified. A LIFT procedure was performed for each patient and they were reassessed for recurrence of symptoms at outpatient followup visits.

Results/Outcomes: CASE 1

A 60-year-old female with a history of obstetrical tear over 30 years prior with chronic anterior anal fissure. She had a perineoplasty 1 year prior to presentation and continued to have granulation tissue and perineal discharge since the operation with a low rectovaginal fistula noted on exam. She first underwent seton placement followed by LIFT procedure 1 month later. At 1 month, 6-month and 10-month followup, she demonstrated complete healing without recurrence of fistula symptoms.

CASE 2

A 74-year-old female with a history of follicular lymphoma who developed severe colitis and proctitis while on treatment with rituximab and bendamustine. She subsequently developed a symptomatic low rectovaginal fistula with drainage per vagina that was demonstrated on exam and MRI. She underwent a workup for new-onset IBD that was ultimately negative. She underwent LIFT procedure and had complete healing 1-month later and no evidence of recurrence at 11-month followup.

CASE 3

A 53-year-old female with a history of ulcerative colitis status post restorative proctocolectomy with ileal J-pouch-anal anastomosis who developed a symptomatic anovaginal fistula with feculent drainage per vagina confirmed on exam and MRI. A seton was placed initially, and she underwent LIFT procedure 2 months later. She developed a small hematoma at the incision that spontaneously drained at her 2-week follow-up. She has no evidence of recurrence at 10-month followup.

Conclusion/Discussion: The LIFT procedure has not been widely described for the treatment of low rectovaginal fistula despite the similarity in anatomy and disease process to fistula-in-ano. We present 3 cases of low rectovaginal fistulas that were treated with the LIFT procedure with complete resolution of fistula symptoms. We believe this demonstrates the feasibility of this technique for treating simple low rectovaginal fistulas. A larger case series and longer follow-up time will be needed to further explore the benefits and limitations of this approach.